Ankylosing Spondylitis: A Treatment Overview
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Ankylosing spondylitis, an inflammatory arthritis and autoimmune condition, has traditionally been a challenge to diagnose. The problem is that it typically starts with back pain, says Carlos Lozada, MD, a professor of clinical medicine in the division of rheumatology and immunology at the University of Miami Miller School of Medicine. “And since back pain is so common, it’s not always recognized that this is a special type of back pain these people have.”
Diagnosing ankylosing spondylitis early is important, though, because the sooner you begin treatment, the better, Dr. Lozada says. The right treatment can help keep your spine flexible and your joints moving. Treating ankylosing spondylitis may also prevent or delay permanent damage to your spine and other joints, including your hips and shoulders, which also may be affected.
Medications prescribed for ankylosing spondylitis include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Disease-modifying anti-rheumatic drugs (DMARDs)
- Biologics, which are immunosuppressants that have been genetically engineered from living organisms
- Corticosteroids (for acute flares)
The best treatment plan for you will depend on what symptoms you have and which joints are affected, as well as any other health conditions you may have. Here's what you need to know about each ankylosing spondylitis treatment option.
NSAIDs for Ankylosing Spondylitis
After an ankylosing spondylitis diagnosis, doctors generally suggest taking NSAIDs first. NSAIDs fight inflammation without using steroids. You can purchase NSAIDs over the counter, or your doctor may write a prescription for a higher-strength dose. Aspirin, ibuprofen, and naproxen are all NSAIDs.
Depending on your prescribed treatment regimen, you may take NSAIDs as needed or on a regular basis to control your pain and stiffness. Different NSAIDs seem to be equally effective in treating people with axial spondyloarthritis, an umbrella term for certain inflammatory spinal conditions, including ankylosing spondylitis, according to a study published inThe Journal of Rheumatologyin March 2019.
NSAIDs work by blocking the enzymes in your body that produce prostaglandins, which are chemicals that trigger pain and inflammation. Therefore, NSAIDs help reduce the amount of prostaglandins you produce and, as a result, improve pain and inflammation, Lozada says.
Some people feel better within a few hours of taking NSAIDs, but it could take a few days to two weeks to notice changes in your symptoms. If you don’t find relief within two to three weeks, talk with your doctor about switching to a different NSAID or trying a different class of medication.
Long-term use of NSAIDs can cause stomach upset and heartburn and make you more susceptible to stomach ulcers. If you have other health conditions like Crohn’s disease, ulcerative colitis, kidney disease, heart disease, or certain other conditions, your doctor may advise you not to take NSAIDs.
DMARDs for Ankylosing Spondylitis
DMARDs may be prescribed if you have ankylosing spondylitis, but they’re a less likely treatment option. DMARDs work best if your knees or ankles are painful and swollen. Although some people who have both ankylosing spondylitis and rheumatoid arthritis (RA) have had success with DMARDs, these drugs don’t seem to help most people who only have ankylosing spondylitis, Lozada says.
“There is some data that sulfasalazine, an older type of DMARD, has some symptomatic benefit for people with ankylosing spondylitis, but it’s not to the same degree you can obtain with newer drugs,” he says.
Methotrexate, a common chemotherapy drug, may also be prescribed for treating ankylosing spondylitis. Doctors generally prescribe smaller doses of methotrexate for ankylosing spondylitis than they would if a person had RA. This medication can be taken orally or by injection. “Methotrexate is not particularly effective for back pain due to ankylosing spondylitis,” Lozada says. “It may help more if the pain is in your hip.”
Biologics for Ankylosing Spondylitis
If you’ve tried two different NSAIDs at full strength and still haven’t found relief, your doctor may consider prescribing a biologic medication. Biologics are the newest class of drugs for treating ankylosing spondylitis, Lozada says.
Biologics offer the most benefit if the joints of your spine are inflamed. Most are tumor necrosis factor (TNF) inhibitors, meaning they work by suppressing production of the TNF-alpha protein, which is known to trigger inflammation. Five biologics are currently approved for the treatment of ankylosing spondylitis — adalimumab, certolizumab pegol, etanercept, golimumab, and infliximab — and each drug is administered either by injection or intravenous infusion. In January 2019, another type of biologic — the IL-17 inhibitor secukinumab — also was approved to treat ankylosing spondylitis. IL-17 is a type of cell that plays a role in triggering the immune response that leads to ankylosing spondylitis. The goal of secukinumab is to turn off this trigger.
Because biologics for ankylosing spondylitis are immunosuppressants, you’re at an increased risk for infection while taking them, Lozada says. In addition, a tuberculosis test is usually required before starting biologic therapy.
Corticosteroids for Ankylosing Spondylitis
Corticosteroids such as prednisone can also help relieve the pain and swelling of ankylosing spondylitis in the short term. However, because long-term use of steroids poses certain health risks, your doctor may be hesitant to prescribe them too often. Corticosteroids can be taken by mouth or injected into the affected joints — the sacroiliac joint in the pelvis, the hip, or the knee — to provide temporary relief. However, they can’t be injected into the spine for ankylosing spondylitis.
Finding the Right Ankylosing Spondylitis Medication for You
It’s essential to work with your doctor to find a treatment plan that’s right for you. People respond differently to different medications for ankylosing spondylitis, so finding the treatment that works best for you may require some trial and error. Regardless of which therapy you’re on, however, you need to talk with your doctor about altering your treatment plan if you don’t see improvement after about three months, Lozada says.
Video: Ankylosing Spondylitis Overview
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